At a
medical meeting in Miami, James Wenz floored fellow orthopedic surgeons
when he showed them a videotape of the hip replacement procedure heís
been using. Most of them, he says, "were pretty amazed." What
staggered the orthopedists was the small incision Wenz makes.

Small in his case
means a 7 centimeter cutabout 3 inchescompared with the foot-long
slit used in conventional hip replacement surgery. With such a minimal
incision, Wenz is able to cut into less tissue and muscle than in the
typical surgery, which for the patient means a less-painful, speedier
recovery. "With this surgery, the majority of people can put their
full weight on their hip the next day," Wenz reports. In the typical
approach, the pain and the time it takes for muscle to repair keep patients
on walkers or crutches for up to 12 weeks.

Making
only a 3-inch incision, orthopedic surgeon James Wenz, above right,
is able to expose the top of the thigh bone (top insert), which he
replaces with a titanium implant (bottom inset). The mini-incision
means faster recovery for the patient.

The main criteria
for pulling off this novel hip replacement is experience. The surgeon
needs to visualize through touch anatomy thatís hidden away. Wenz, whoís
done more than 300 of the procedures, is able to figure out precisely
where to operate by studying preoperative X-rays and by very carefully
palpating the terrain of the hip beneath the skin to form an image of
its shape and location. His incision needs to provide access to both the
top of the femur or thigh bone, in which he will insert the stem and head
of the implant, and the hip socket, where he will attach a plastic-lined
metal cup that houses the head. A mistake of just centimeters wonít allow
enough room to insert the implant. "If you donít get the location
absolutely perfect, you canít do the procedure," Wenz makes clear.

Some orthopedic surgeons
have been reluctant to do the mini-incision hip replacements, because
in early operations there appeared to be a greater likelihood that the
implant would fall out of the hip socket. Wenz has avoided that problem
by preserving the capsule of tissue that extends from the socket to cover
the head or ball of the implant stem. In the conventional approach, this
tissue is removed.†

"We cut it open
and fold it out, and then at the end of the procedure fold it back in
and suture it down," Wenz explains. The process reduces risk of dislocation.

The two categories
of patients for whom the procedure doesnít work are those with unusual
hip anatomy and people whoíve already had hip-replacement surgery. But
Wenz now uses the technique on almost all of his patients and believes
that as instruments evolve and surgeons become more confident with the
approach, it will become the standard way to do total hip replacement.

The teeth marks on
Thomas Alva Edisonís original phonograph tell all, says otolaryngologist
Lawrence Lustig, M.D.: Edison, who Lustig says "probably had a pretty
good working cochlea or inner ear, but also some major conductive hearing
problems, used to bite down on the record playerís wooden exterior to
get the sound to his inner ear so he could hear what was coming from the
phonograph. Because bone is an effective transmitter of vibrations, it
can carry sound waves to the inner ear in people with damaged middle and
outer ears.

Otolaryngologist
Lawrence Lustig snaps a hearing aid onto the tiny, titanium post embedded
in the skull of patient Phyllis Earhart, giving her left ear the ability
to hear for the first time.

Were Edison alive
today, Lustig could offer another way to help his hearing problem. By
implanting a tiny titanium post into the mastoid bone behind the ear,
the otolaryngologist gives patients with conductive hearing loss, due
to blocked or underdeveloped ear canals, a means to amplify sounds to
their inner ears. In the 30-minute outpatient operation under local anesthesia,
Lustig first cuts a small horseshoe-shaped flap behind the ear, and drills
a small pilot hole to house a post, which he screws and embeds firmly
into the bone. Then, he removes soft tissue over the bone so the patientís
skin will adhere to it the way skin sits on a fingernail bed, tight and
immobile. Finally, Lustig places a small mounting bracket on the screw,
which actually rises above the surface of the skin, for the hearing aid.
After three months of healing, the aid is snapped to the post and turned
on.

A recent study of
40 patients whoíd had the procedure showed that amplification improved
dramatically in 80 percent. "Itís fantastic," says 67-year-old
Phyllis Earhart of Red Lion, Pa., who had lost all hearing in her left
ear because of calcium deposits. "Now I can hear like everyone else."

Because conventional
hearing aids and ear surgery are not options for patients like Earhart,
many would remain significantly hearing-impaired without the procedure,
which is available at only a handful of U.S. centers.

In another step forward
on the hip-replacement front, orthopedic surgeons Michael Ain and Frank
Frassica have come up with techniques that make the operation available
to a group of patients whom doctors usually turned awaythose whose
full height is under 4 feet because of stunted and deformed bone growth
known as skeletal dysplasia.

Until recently, the
specially designed artificial hips and surgical tools necessary for people
this small werenít available. "You canít just take an off-the-shelf
artificial hip," Ain explains. The diminutive, irregular bone structure
and poor bone quality of these patients also makes them technically challenging
for surgeons to operate on, as do conditions like neck instability. "Physicians
would simply tell them they werenít candidates for the hip surgery,"
Ain says.

Now Ain and Frassica
have collaborated with biomedical engineers to design smaller prostheses
and instruments, especially adapted to these patients. They use a dental
burr-like instrument, rather than a conventional orthopedic drill to carve
out a canal in the thigh bone for the stem of the hip implant. They also
create smaller, computer-generated prostheses with special CT scans.

Key to success in
these complicated cases is surgical experience and clinical expertise.
Historically, Hopkins has had a large interest in skeletal disorders,
Ain notes, citing the world-renowned Greenberg Center for Skeletal Dysplasias:
"It lets us push the envelope in offering new kinds of help to these
small people."

Charlie Rigglemanís
scar could have killed him. The three-foot long markan aftermath
of three open chest surgeriesstretched from the middle of his back,
around his side, and across the length of his belly. The tissue was so
dense it had caused one of Rigglemanís lungs to adhere to his chest wall.

Such was the situation
when a Pennsylvania doctor noticed a balloonlike bulge in the aortic artery
just above the 72-year-old Rigglemanís heart. Riggleman, who had coughed
up a washbasin full of blood, was at a very high risk of bleeding to death.
The aneurysm needed repairing, and quickly, but surgeons were reluctant
to perform another invasive chest operation. The scar tissue was blocking
access to the aorta, making surgery both difficult and risky.

Only one option remaineda
minimally invasive procedure now being tested here by interventional radiologist
Lawrence "Rusty" Hofmann, M.D. Itís a technique available at
only about a dozen sites worldwide. "But," says Riggleman, "it
was the only logical choice."

Unlike conventional
surgery in which a large incision in the patientís side or abdomen provides
access to the aorta, this new approach relies on catheters to enter the
giant artery. First, a surgeon makes a three-inch incision in the groin
and femoral artery. Then, using real-time X-ray imaging, Hofmann inserts
a catheter containing a 6-inch wire tubea stent graftat its
tip and slides the catheter up the aorta to the thoracic region until
the graft extends just above the aneurysm.

"Itís especially
tricky when the aneurysm is in the arch of the aorta," Hofmann admits,
because itís close to the artery that supplies blood to the left arm,
and you donít want to block that with the graft.

Once the stent is
in place, Hofmann quickly pulls a tiny string that releases the self-expanding
tube. Immediately, blood begins to flow through the graft. Within hours,
the aneurysm clots and over time diminishes in size.

The novel technique
offers a number of benefits. Unlike the open procedure, the aorta doesnít
have to be clamped, which means organs like the kidney or liver are not
at risk of failing, due to loss of blood and oxygen. Also, the procedure
takes about an hour, while conventional surgery usually lasts six-to-nine
hours. Patients spend several days in recovery, compared with two or three
weeks after open-chest surgery.†††††††††††

Many people with
thoracic aneurysms are candidates for the catheter approach, according
to Hofmann. But the best are those, like Riggleman, who cannot undergo
conventional surgery because of pre-existing health problems, previous
surgeries, or age. Although the procedure is still being tested, Hofmann
expects FDA approval by 2002.†††

Riggleman himself
offers the most convincing testimony. Having gone through a number of
invasive procedures, "I know what a great thing this is," he
says. "In fact, Iíd call it miraculous."

Thereís no way that
growing up with a sunken chest canít be depressing. Because the chest
wall curves sharply inward and presses against the heart and lungs, a
child becomes so easily winded that taking part in sports usually becomes
problematic. Additionally, the shrunken appearance of the chest and the
protruding belly caused by the birth disorder can draw jeers from classmates.

Surgery for the condition,
in which the childís breastbone, or sternum, is broken and pushed out
to expand the chest wall, has been generally effective in restoring full
breathing capacity and correcting an odd-shaped appearance. But occasionally
the repositioned sternum either protrudes too far or sinks back requiring
another operation. "The chest doesnít look entirely normal in these
cases," explains pediatric surgeon Paul Colombani, M.D., "and
the chest wall doesnít expand to its full capacity."

Rather than
open the chest to expand it, surgeon Paul Colombani inserts a curved
stainless steel bar through the two small incisions on the side of
the chest (inset).

Now, in a new, minimally
invasive modification of the surgery, called the Nuss procedure, Colombani
and surgeon Charles Paidas, M.D., have reduced the likelihood of such
mishaps while improving the patientís appearance. Rather than opening
the chest and cracking the sternum, they insert a curved stainless steel
bar beneath the sternum through two small incisions on the side of the
chest and stitch the bar to the ribs. The bar then pushes the sternum
outward and over a two-year period remolds the chest wall. At the end
of the process, surgeons slide it out.

"Because nothing
has been cut, the likelihood of the chestís falling back down is minimized,"
Colombani says. "The repair not only is less invasive, but takes
less time, so recovery is faster and less painful for children."
The Nuss procedure takes 90 minutes compared with the four-hour open surgery.

To understand the
connection between prolapse in women and childbirth, gynecologist Geoffrey
Cundiff, M.D., suggests we think of the birth canal as a sock. As the
baby passes through it, the sockís threads or fibrous connective tissues,
which hold the structures of the pelvis in place, are torn away. Over
time, as the tissues continue to stretch and tear, pelvic organs like
the bladder can protrude into the vagina. The result is pelvic organ prolapse,
the leading cause of incontinence in women.

"Stress incontinence
is a support problemloss of support in the bladder neck, the bladder
itself or at the top of the vagina," says Cundiff. "Whatís causing
this lack of support are hernias. The tissues have torn."

The traditional treatment
for the condition has been shortening and reattaching the tissues through
abdominal or vaginal surgery. But patients typically spend six weeks at
home recovering. Now, Cundiff and his colleagues are offering minimally
invasive laparoscopic techniques with less postoperative pain and a shorter
recovery time, and equally good results. Through laparoscopic pelvic reconstructive
surgery, one of the newest applications of laparoscopic technology, Cundiff
has also found a way to fix multiple structural problems in one operation.

In the first step,
known as the Burch procedure, Cundiff elevates the sagging bladder neck
by suturing it to a ligament on the pubic bone. Next, in a cystocele repair,
he stitches to the sidewall of the pelvis connective tissue that supports
the bladder itself and which has herniated into the vagina. Similarly,
he rebuilds support tissue at the top of the vagina, a procedure known
as a† uterosacral suspension. The biggest challenge in performing this
three-in-one procedure laparoscopically, says Cundiff, is suturing.

"Most surgeons
try to avoid suturing by using mesh and staplers, which sometimes fail.
We donít fail because weíre doing a real Burch in the same way you would
in an open procedure."

Putting a patient
on a treadmill and then measuring blood pressure, breathing and heart
rates is an accepted way for physicians to detect signs of coronary artery
disease. But stress testing only picks up blockages that are at least
60 percent obstructive, notes cardiologist Roger Blumenthal, M.D. "By
then, the horse is already out of the barn with significant disease of
the arteries," and it may be too late to use preventive measures
to avoid invasive bypass surgery or angioplastyexpanding the narrowed
artery with a balloon. To get around that problem, cardiologists here
are using a new type of CT scan, called Electron Beam Tomography, or EBT,
that is allowing them for the first time to observe signs of coronary
blockages before chest pain and shortness of breath start occurring.

An EBT Scan,
says cardiologist Blumenthal, is the first proven, non-invasive
way to detect very early development of plaque in the arteries.

Blumenthal says that
until now thereís been no proven, noninvasive way to see this very early
development of plaque in the arteries EBT, which is performed in less
than five minutes on a fully clothed patient lying on an open table, works
by taking stop-action images of the beating heart, 20 times faster than
any previous method. The technique produces images of calcium buildup,
which shows up as white specks on the walls of arteries, before these
specks develop into calcified plaque. By determining the amount of coronary
calcificationthe tip of the atherosclerotic icebergcardiologists
can better predict the personís risk of a cardiac event over the next
five years.†

"If indeed you
have coronary calcification, you may not have a significant amount of
rust, or obstruction, in the pipes," Blumenthal says. "But we
can clearly see abnormalities that predict future blockages."

Thatís exactly the
information thatís necessary to prescribe preventive treatment to a symptom-free
patient and reduce the risk of a debilitating heart attack. About 650,000
of the estimated 1.5 million heart attacks this year, according to the
American Heart Association, will be the patientís first indication of
coronary artery disease. One in four of those first-time victims will
die.

"With a coronary
calcium scan, along with a good history, physical and lipid profile and
other blood tests, we can determine what an asymptomatic personís risk
is with a high degree of certainty," Blumenthal says. "And knowing
where they stand may motivate patients to rev up their lifestyle with
exercise and diet."

The thick mucus that
clogs the lungs in the incurable hereditary disorder cystic fibrosis usually
comes to light first during childhood when the patient suffers repeated
bouts of bronchitis and sinusitis. But a lot of† patients with these classic
symptoms reach adulthood without a physicianís ever connecting them to
CF. Itís not hard to understand why: The traditional screen for CF is
a sweat test that measures the amount of salt in perspirationpeople
with the disease canít absorb salt and release abnormally high amounts
in their sweat. In a small percentage of those with the disease, however,
the sweat test shows nothing.

Now a test available
at only a few centers around the country makes the diagnosis unequivocal.
Called the nasal potential difference study, it measures the flow of chloride
ions into and out of cells controlled by the protein whose deficiency
causes CF. "Itís the ultimate test for determining if somebody has
cystic fibrosis," says pulmonologist Michael Boyle, M.D.

To administer the
painless one-hour test Boyle places electrodes on the lining inside the
patientís nose, where the chloride channel is similar to that in the lungs.
Then he uses a thin strawlike tube to expose epithelial cells in this
lining to chemical solutions to stimulate the chloride channel function.
If the chloride channel is turned on by these solutions, as recorded by
a small electrical current through the electrodes, the patient doesnít
have CF.

Boyle makes clear
that this foolproof test is key for any patient who exhibits CF-like symptoms.
The earlier the diagnosis, the better the chances of early treatment with
antibiotics and anti-inflammatories, slowing the progression of lethal
lung damage. Unchecked, the damage will nearly always lead to death or
the need for a lung transplant.

"There are treatments
that target the various classes of CF," Boyle points out, "but
you have to have the diagnosis to know which therapies are best suited
for each patient."

Epilepsy is a complicated
disease: Trying to find what sends areas of the brain into apparently
spontaneous waves of firing keeps thousands at work in pharmaceutical
companies around the world.† Some scientists focus on cellsí producing
too much of a stimulatory nerve transmitter. Others say seizures come
when something goes awry with the release of an opposing nerve transmitter
called GABA (for gamma amino butyric acid)† that normally damps down excitable
nerve cells.

But Hopkins neurology
researcher Jehuda Sepkuty, Ph.D., offers evidence of still another possible
glitch: something may lessen the steady supply of molecules a nerve cell
uses to synthesize GABA. The less GABA to quiet target nerve cells, the
greater the likelihood of target cells becoming excitablelike taking
a restraining hand off a feisty 4-year-old.

Sepkuty suspects
the source of the problem is a molecule called EAAC1, which ferries GABAís
molecular building blocks into key nerve cells. Once inside the cell,
precursor molecules become part of the inhibitory neurotransmitter GABA.†

In the study heís
presenting, Sepkuty studied rats genetically engineered to produce less
EAAC1.† The rats exhibited episodes of staring and seizures. They also
had hyperexcitable limbic systems in the brainall characteristics
of epilepsy.† The ratsí cells also produced less GABA than normal. "We
know this is rat epilepsy weíre seeing.†Weíre not sure if this is the
human version, though all the signs appear the samethatís our next
investigation," says Sepkuty. "But because this is a completely
new approach to what may go awry in some epilepsy patients, it offers
us novel sites for drug therapy," adds co-researcher Jeffrey Rothstein,
M.D., Ph.D.

When doctors at a
major Mid-Atlantic teaching hospital told John Auldridge† last year that
his liver cancer was inoperable and nothing more could be done to help
him, the 69-year-old Dagsboro, Del., man rushed for a second opinion.
He got a better prediction from Hopkins interventional radiologist J.F.
Geschwind, M.D., who had helped develop a new way to kill liver tumors
through a catheter. Within weeks, four of the five lesions in Auldridgeís
liver had been destroyed, and the fifth was scheduled for similar demise.

"This is a patient
who had unresectable liver tumors with a life expectancy of six months
or less," Geschwind says. "Now heís almost tumor-free."

Interventional
radiologist J.F. Geschwind points to liver lesions that have been
killed by a mix of chemo drugs and an oil derived from poppy seeds.

The treatment, called
chemoembolization, is a palliative measureone that has been shown
to extend the lives of patients rather than completely cure them. In the
procedure, Geschwind feeds a catheter through the femoral artery from
the groin to the liver artery that supplies blood to the tumor. He then
injects a mix of chemotherapy drugs and an oil derived from poppy seeds
that acts as an emulsion to prevent the chemo agents from washing out
of the lesions. The formula works both by blocking the blood supply that
feeds the tumor and killing cancerous cells within the lesions. Geschwind
explains that the chemotherapy is carried to the tumor by the oil, and
because the mix is somewhat viscous, it will stay confined to the tumor.

Geschwind uses oil
in his mix because Japanese studies have shown that the liver tumor sucks
up and accumulates this substance, like a sump pump. At the end of the
infusion, Geschwind may also add particles to prevent the chemo drugs
from washing out of the liver.

The results? Of this
radiologistís patients with inoperable liver tumors, 80 to 88 percent
have survived for one year and 60 to 75 percent for three years. Untreated,
patients usually die within three to six months of diagnosis. "We
were practically in tears," Auldridge said of the procedure. "Any
extension of† life is priceless, even if itís just two or three years."